SDoH Name(Required) First Last Email(Required) Contact PhoneInstructions : Please read each question carefully before responding, circle the choices that best fit your responseDo you have any of the following conditions? Please select all that apply Cancer Asthma or COPD Stroke Diabetes/Prediabetes/Impaired blood sugar Sickle Cell Disease Current smoker Obesity or severe obesity Chronic kidney Disease Neurological conditions like Dementia, Alzheimer’s etc Sight loss Immunocompromised due to solid organ transplant Mental health condition Heart conditions such as heart failure, coronary artery disease, or cardiomyopathies Substance use Hearing loss Chronic pain (lasting more than 3 months) None of the above Prefer not to answer Other, please specify Are you currently covered by any form of health insurance or health plan? A plan through my employer A plan through my spouse’s employer A plan I purchased directly from an insurance company A plan through the health insurance marketplace A plan through my parents Medicare Medicaid Private insurance I don’t have insurance Other Have you ever tested positive for COVID 19 infection? Yes No Unsure If yes, please select from below all the symptoms you experienced Fatigue Fever Shortness of breath Cold or sore throat Headache Chills Nausea or vomiting Loss of taste and smell Muscle aches Cough Diarrhea Others Please select from below your COVID-19 vaccination status Fully vaccinated (received second dose of two dose COVID-19 vaccine series or one dose of single dose COVID-19 vaccine. Up to date (received booster shot as well) Partially vaccinated (at least two weeks have passed since first dose of COVID-19 vaccine) Not vaccinated but want to get vaccinated Not vaccinated and don't want to get vaccinated Did you have or continue to have any COVID-19 infection related symptoms lasting 3 months or longer that you did not have prior to having COVID-19? Select all that apply Tiredness/ fatigue Difficulty thinking/ concentrating Menstrual changes Joint/muscle pain Inability to exercise Changes in taste/smell Frequent forgetfulness/memory problem(brain fog) Breathing difficulties Fast beating/ pounding heart None of the above What would most help you have a better life today? Select all that apply Food Flu Vaccine Health insurance Childcare Rent Other vaccines Transportation Caregiver support Utilities Insurance Personal safety Internet Housing Primary care or other healthcare Help with loneliness Education COVID Vaccine Finances Employment Supportive care/services (e.g. grief groups, alcohol anonymous, narcotics anonymous, other support groups) There is nothing I need help with Prefer not to answer Others Do you have a Primary Care Provider or Doctor? Yes No Prefer not to answer In the past 12 months, how often have you visited the Emergency room for your healthcare needs? 1-3 times 4-6 times I have lost count I have not visited the ER in the past 12 months for my health needs Do you use any of the following tools to monitor your health? Select all that apply Smart watch, apple watch, Fitbit etc. Oura ring Blood pressure monitor Health/fitness apps Blood glucose monitor Heart monitoring devices Pulse oximeter Weighing scale None of the above Prefer not to answer If provided, would you be open to utilizing one of the previously mentioned health monitoring tools to help you keep track of your health? Yes No Are you Hispanic or Latino? Yes No What is your age?What is your gender? Male Female Non-binary Prefer not to say What race are you? White Caucasian African American Asian Pacific islander Native Hawaiian American Indian/Alaskan native Other Prefer not to answer What is your highest level of education? Less than high school High school diploma or GED More than High School I prefer not to say What is your current work situation? Part-time or temporary work Full-time work Self-employed Retired Unemployed but not seeking work Unemployed and seeking work During the past year, what was the total combined income for your and the family members you live with? This information will help us determine if you are eligible for any benefits:Under $15,000$15,000-$24,999$25,000-$34,999$35,000-$49,999$50,000-$74,999$75,000-$99,999Over $100,000Is there anything else, not previously asked, that you would like to include that you feel has impacted your health status? Please specify below:CAPTCHAEmailThis field is for validation purposes and should be left unchanged.
